Provider Demographics
NPI:1659115673
Name:MIKELSON, NIKLAS WALTER (FNP-C)
Entity type:Individual
Prefix:
First Name:NIKLAS
Middle Name:WALTER
Last Name:MIKELSON
Suffix:
Gender:M
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 SHENANDALE DR
Mailing Address - Street 2:
Mailing Address - City:MCGAHEYSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22840-2148
Mailing Address - Country:US
Mailing Address - Phone:804-586-4425
Mailing Address - Fax:
Practice Address - Street 1:250 MEMORIAL DR STE D
Practice Address - Street 2:
Practice Address - City:LURAY
Practice Address - State:VA
Practice Address - Zip Code:22835-1000
Practice Address - Country:US
Practice Address - Phone:804-586-4425
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-24
Last Update Date:2024-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024190524363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily